SECTION 400 PART C: FOR BILLING FORMS

REVISED: 01/25/10

DSB-4020 PHARMACY AGREEMENT

DSB-4020, Pharmacy Agreement

PURPOSE

DSB-0511 is used by pharmacies that have signed a working agreement (DSB-4020: Pharmacy Agreement) with the Division of Services for the Blind to provide pharmaceutical services to consumers of the agency. These drugs include those authorized for individual consumers for diagnostic, palliative, or therapeutic purposes.

Prescription drugs will be billed at cost plus a professional dispensing fee set by DHHS. It will be the responsibility of the Program Benefit/Payment Section of the Department of Health and Human Services to ensure that the First Data Bank Price Alerts Blue Book costs are correct.

It is the responsibility of the Nursing Eye Care Consultant approving the bill to be sure that the professional fee has not been charged more than one time per calendar month per prescription drug per consumer.

INSTRUCTIONS

Preparation: For each client, submit one claim monthly that contains all charges for a single calendar month. In items 1-8, enter the information requested.

In spaces 9(A) through 9(I), enter the information about prescription drugs as described below (NOTE: A prescription drug is defined as one that bears the statement “CAUTION: Federal Law Prohibits Dispensing Without Prescription” on the label of the manufacturer’s original package. Assigning a prescription number to a non-prescription drug does not make it a prescription drug, even if a prescription has been issued. Exception: All pharmacist-compounded prescription orders are considered to be prescription drugs.):

9(A) The prescription (or file) number assigned by the individual pharmacy.

9(B) The brand name (proprietary name) of the drug actually dispensed, or the generic name (non-proprietary name) of the non-branded drug actually dispensed.

9(C) The National Drug Code (NDC) number assigned to the product actually dispensed.

9(D) The concentration of drug per unit volume or per unit weight.

9(E) The quantity of drug dispensed, e.g., number of tabs, caps, ml, cc, oz.

9(F) The date the prescription order was actually filled.

9(G) The estimated number of days the dispensed quantity of drug should last if used in accordance with the prescriber’s directions.

9(H) The cost of the drug. The amount you enter here will be compared to the maximum cost allowed by the Medicaid Program. If you intend to bill your usual charge to the public, you must deduct the dispensing fee here. The dispensing fee is billed in item 11(B). [NOTE: drugs covered by the Maximum Allowable Cost Program (MAC) will be reimbursed at MAC rates unless (1) a prescriber override has been made, and (2) the letters “OA” have been entered in the last two digits of the NDC number to indicate the override.]

9(I) Please indicate B for Brand or G for Generic drug.

In spaces 10(A) through 10(H), enter the information about pharmacy/OTC items as described below:

10(A) The prescription (or file) number assigned, if any, assigned by the individual pharmacy.

10(B) The brand name (proprietary name) of the drug or item actually dispensed, or the generic name (non-proprietary name) of the non-branded drug or item actually dispensed.

10(D) The concentration of drug or item per unit volume or per unit weight.

10(E) The quantity of drug dispensed, e.g., number of tabs, caps, ml, cc, oz.; or items.

10(F) The date the order was actually filled.

10(G) The estimated number of days the dispensed quantity of drug or item should last if used in accordance with the prescriber’s directions.

10(H) The dispensing pharmacist’s usual charge for the drug or item.

Item 11(a) Enter total cost of the drugs in Section 9.

(b) In the first blank, enter the lower of: 1) the allowable Medicaid dispensing fee in effect at the time the prescription drug is dispensed, or 2) the usual and customary dispensing fee charged to the general public for the same service. In the second blank, enter the total number of prescriptions dispensed in Section 9. Multiply, and enter the result in the third blank. Do this for both brand name and generic drugs.

(c) Enter total usual charge for pharmacy OTC items in Section 10.

(d) Enter total of a, b, and c.

Mailing: Mail copy to: Division of Services for the Blind local district office at the address listed on top of the authorization.

Disposition: Copies of this form retained by state agencies may be destroyed in accordance with the Records Disposition Schedule published by the N.C. Division of Archives and History.

TERMS AND CONDITIONS

1. I understand that the programs of the Division of Services for the Blind pay the Medicaid rate of reimbursement for prescription drugs and other items (the rate in effect at the time a claim is received) and that this includes reimbursement for MAC drugs.

2. I understand that payment is available only for service which has been authorized by a program and that claims must be received by the Division within one year after the dispensing date in order to be paid.

3. I understand that payment is available only for services not covered by another third party payer and that Medicaid must be billed for any service that can be paid by Medicaid.

4. I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, and statements or documents, or concealment of a material fact, may be prosecuted under the applicable Federal and State laws.

5. I understand that payment is subject to the availability of funds.

6. I will accept payment by the Division of Services for the Blind as payment in full for services rendered.

WEBSITE: DSB-0511 Pharmacy Billing Form

CLAIM NOT VALID UNLESS SIGNED ON THE REVERSE BY DISPENSING PHARMACIST

HCFA-1500, Health Insurance Claim Form

HCFA-1500: Instructions for completing the HCFA-1500 Claim Form

PURPOSE

To provide written verification that individuals have received items authorized for them by North Carolina Division of Services for the Blind (DSB) staff on DSB-0608: Authorization and Billing Invoice.

PREPARED BY

Prepared as a parallel document to DSB-0608, Authorization and Billing Invoice, by DSB Staff.

DSB-0950, Verification of Items Received

DSB-0950, Verification of Items Received Instructions